In the shadow of HIV & TB: A commentary on the COVID epidemic in South Africa

ABSTRACT

While COVID-19 has become a global pandemic that has spread to all regions of the globe, local historic, health, and socio-environmental factors shape the epidemiological contours, response, and social challenges present within each affected nation. Thus, while countries like China, Italy, Iran, Brazil, and the United States have all been hard hit by the pandemic, there are critical differences across these nations in a number of variables (e.g. demographic features, health histories, healthcare systems, infection case rates, case fatality rates, national responses). In other words, within the global pandemic there are multiple importantly distinct national epidemics. Overcoming the grave threats to public health presented by COVID-19 requires both international cooperation and country-specific efforts that reflect local histories, needs, and resources. Already concerns are being expressed among health officials about how COVID-19 might be devastating in Africa. Currently, South Africa has the highest number of diagnosed COVID-19 cases on the continent and has been identified as being at high risk in the pandemic. This paper examines the public health response to the COVID-19 threat, how the prior and ongoing HIV and TB epidemics shape the COVID-19 epidemic and influence the response, and the potential ramifications of the response.

KEYWORDS:

• COVID-19
• HIV
• TB
• South Africa
• syndemics

Introduction

While COVID-19 has become a global pandemic that has spread to all inhabited regions of the planet, local historic, health, and socio-environmental factors shape the epidemiological contours, response, and social challenges present within each affected nation. As noted by Segata (2020) with reference to the pandemic, ‘we need to keep in mind that global events are always enacted from and in local contexts. They are performed from and in local materialities and practices’. Thus, while countries like China, Italy, Iran, Brazil, and the United States have all been hard hit by the pandemic, there are critical differences across these nations in a number of key variables (e.g. demographic features, health histories, healthcare systems, infection case rates, case fatality rates, national responses). As noted by Charles Rosenberg (1989, p. 2),

Epidemics constitute a transverse section through society, reflecting in that cross-sectional perspective a particular configuration of institutional forms and cultural assumptions. Just as a playwright chooses a theme and manages plot development, so a particular society constructs its characteristic response to an epidemic.

In other words, within the global pandemic there are multiple importantly distinct national epidemics.

This is not a unique feature of COVID-19 but is characteristic of all global pandemics. At an early point in the HIV/AIDS pandemic during the 1980s, for example, the World Health Organisation differentiated between Pattern 1 countries (industrialised countries where most cases were among homosexual and bisexual men, illicit injection drug users and their sex partners, and the male to female ratio was about 10:1), Pattern II countries (developing countries in sub-Saharan Africa, the Caribbean, and Latin America in which heterosexual transmission predominated), and Pattern III countries (countries in which AIDS cases and HIV infections was low, with no mode of HIV transmission predominating) (Chin & Mann, 1990; Piot et al., 1988). Such diversity was proving a barrier to global coordination efforts, as HIV/AIDS was conceptualised as unique regional epidemics rather than a shared global pandemic (Piot et al., 1988). Similarly, a global mortality assessment of the 2009 H1N1 influenza pandemic found prominent regional mortality variations were explained by the age structure of countries, country location (i.e. latitude), the specific A and B viruses in circulation, air pollution levels, and the prevalence of other infectious diseases (e.g. HIV and TB) (Morales et al., 2017).

For this reason, while COVID-19 is without doubt global in its impact, understanding the pandemic requires an examination of specific cases at different scales. As Mehtar et al. (2020) argue with reference to the countries of Africa, as COVID-19 spreads across the continent, ‘causing disruption of already fragile health systems, it is becoming clear that responses require action beyond the health sector and must be tailored to the local situation’. Here we consider the case of COVID-19 in South Africa to clarify some of the unique features that differentiate South Africa’s pandemic experience from that of other nations(Gilbert et al., 2020). We focus on South Africa’s response to the COVID-19 threat, how HIV-related syndemics shape the COVID-19 epidemic and influence the response, and the potential long-term ramifications of the response. Assessment of this case provides insights on how history shapes the present, including how individual societies caught up in a global pandemic construct differing mitigation strategies with different outcomes.

Coming of COVID-19 and South Africa’s highly restrictive response

On 27 March 2020, South Africa entered into one of the world’s most stringent nationwide lockdowns in an effort to control rapidly increasing cases of COVID-19. At the time, the country had 1,000 cases and one confirmed COVID-19-related death; the highest counts on the continent (Bearak, 2020). The first case was confirmed on March 5 – a 38-year old male who returned from a group travel experience in Italy (Mkhize, 2020). The first cases appeared to be confined to suburban areas and largely involved wealthier travellers from Europe, the United States and other countries (Bauer, 2020). By early April, officials confirmed the first COVID-19 infections in the sprawling low-income townships of Alexandra and Khayelitsha outside of the cities of Johannesburg and Cape Town, respectively (Bauer, 2020). The most populated provinces (Gauteng, KwaZulu Natal, and the Western Cape), which include the major cities of Johannesburg, Pretoria, Durban, and Cape Town, are now seeing the majority of cases.

In response to the growing number of cases in the South Africa, President Cyril Ramaphosa decided to enact very strict measures to limit the exponential growth of the local epidemic. Under a ‘level 5’ threat, all borders were closed and all domestic and international flights prohibited. Only essential service providers, such as healthcare workers, financial services, journalists, and retail workers, were allowed to work. Businesses that provide essential services were required to get a special government permit that allowed their staff to travel. All train services were stopped immediately and only limited bus, mini-bus and taxi services were maintained during specified hours and with limited passenger capacity (SABC, 2020). Under ‘level 5’ lockdown, restrictions included no jogging outside, no sales of alcohol or cigarettes, no dog walking, no leaving home except for essential trips such as seeking care, grocery shopping, and collecting welfare grants. Anyone breaking the law risked prison or heavy fines. Additionally, spreading ‘false information’ about the coronavirus was criminalised and punishable by up to six months in prison, a fine, or both.

South African colleagues we contacted during the lockdown mostly indicated that these harsh measures were justified, and hailed the government as transparent and presenting clear communications. Day-to-day life was restricted, but everyday essentials were available. People presented communal sentiments of solidarity during a shared experience of risk, some making facemasks and donating food and supplies to community groups, religious organisations, and orphanages. As noted by a university student living in a suburb of Pretoria, ‘We are all fine. I phone my friends who live in the townships and they also say they are fine. They say they are safe’.

However, the lockdown has not brought everyone the experience of simply a slower daily pace, zoom family gatherings and happy hours, and binge video streaming. Stated journalist Patrick Bond (2020) in his headline, ‘COVID-19 attacks the down-and-out’. Personal accounts and journalistic reports indicate that the rigid lockdown has been especially hard on low-income families and individuals. A man sitting on the street drinking a beer commented to journalist John Sparks of SkyNews on March 29, ‘I am staying in one room with five others, how can I stay in there all day? They must just come and arrest us’ (Bond, 2020). A taxi driver in Johannesburg expressed, ‘First, I am out of work, so no money … and then I stay at home, and we don’t know what will happen in three weeks. The virus may go everywhere. People are scared. It is very, very, very difficult’ (Bearak, 2020). Domestic workers, of which there are an estimated 1.3 million in South Africa, a sector made up mostly of Black women, often lack formal contracts with their employer. During the lockdown, some were not able to leave their homes to get to work. For example, one domestic worker in Johannesburg was told by her employer, ‘No work. No pay’ (Powell, 2020). Others, according to the United Domestic Workers of South Africa, are blocked from returning home to their families as employers are afraid that when they return from home they will infect the employer’s families (Powell, 2020). While both of these actions are illegal (Tanzer, 2013), the nation’s labour courts are closed for the lockdown.

Many are concerned that they will have no essential services under lockdown as financial mismanagement and corruption has plagued the country’s state-run water and electricity companies (Bearak, 2020). South Africa’s constitution provides for 6000 litres of water per household per month, but additional use in low-income areas is accessible only through pre-payment metres. Given that people are at home more often, with no jobs to go to, household water use is greater than usual, and travel to reload vouchers is restricted. Water is becoming a significant concern creating potentially dangerous conditions for spreading the virus. According to Housing and Water Minister Lindiwe Sisulu, 2000 densely-packed townships, inner-city areas and rural villages are ‘urgently in need of assistance’ merely for clean water provision. On March 17, Sisulu announced that water and sanitation measures would be provided in high-density public areas, informal settlements, and rural areas (Human Rights Watch, 2020). Communal water tanks have been provided to some of the more severely affected communities. By April 26, 4775 water tanks had been delivered to various communities in the Eastern Cape Province, with 3074 installed (Department of Water and Sanitation, 2020).

As a result of prior conditions and the added burdens of the COVID-19 national response, there has been ‘a sharp increase in national levels of poverty and malnutrition’ (Egan, 2020). While wealthier South Africans can rely on continued salaries or savings to tide them through the lockdown, for the poor and working class there are no reserves to use to buy food. People who work in the informal sector have lost their day-to-day source of livelihood. While for the poor, adequate nourishment was a struggle before the lockdown, growing numbers are now unable to provide for themselves and their families.

In an effort to clear the streets of all potential threats, the army and police, supported by armoured personnel carriers, moved thousands of homeless people off the streets. Across the country, the homeless were transported to open fields, empty school grounds, and stadiums where makeshift shelters were setup. In Cape Town, media accounts of a homeless camp on a sports stadium outside the city indicated that camp residents felt forcibly detained, with limited access to information, and poor living conditions (Kriesch, 2010). In Pretoria, the nation's capital, at least 1000 homeless men were rounded up and crammed into a soccer stadium. Inside the stadium, green army tents, meant to house three persons each, were soon home to ten per tent (McKenzie & Swails, 2020). Many chose to sleep out in the open on the stadium bleachers.

Attempts to enforce the lockdown have turned violent. Within the first seven days, security forces arrested more than 2000 people for allegedly flouting the regulations (Human Rights Watch, 2020). On April 22, more than 70000 extra troops were deployed, the country's biggest military deployment for domestic purposes since the end of the Apartheid government and the dawn of democracy in 1994 (Maseko, 2020). In Hillbrow, an inner-city Johannesburg neighbourhood, police and the army used whips, rubber bullets and tear gas throughout the first week of lockdown to disperse people who were not heeding the call to self-isolate at home or respect social distancing polices (Bauer, 2020). More than a dozen soldiers are under investigation after allegedly killing a man in Alexandra township (BBC News, 2020d). An issue motivating protests against the lockdown was a lack of access to food (Egan, 2020).

Two dozen African countries have, like South Africa, fully closed their borders, and 10 more have closed their airports to international traffic (Bearak, 2020). Rwanda began a lockdown on March 22. Kenya has locked down Mandera county given a high number of cases, restricted movements between counties, imposed curfews, forcibly quarantined confirmed cases, and required the wearing of facemasks when using public transportation (Shaban, 2020). Uganda banned public transportation; Eritrea has closed most public institutions; Nigeria has banned travel between states. Movement restrictions between Kinshasa, the capital of the Democratic Republic of the Congo and one of Africa’s largest cities with at least 14 million people, took effect March 26, and a four-day-on, two-day-off lockdown cycle started within the city on March 28 (Bearak, 2020), a decision that was reversed on April 2. Public gatherings, markets, bars, restaurants, schools, and universities were also closed in Kinshasa. However, no African country has been as forceful and far reaching in imposing its lockdown as South Africa.

South Africa announced an easing of lockdown restrictions beginning in May, dropping the alert status from ‘level 5’ to ‘level 4’ (BBC News, 2020c). On May 1, some businesses were allowed to reopen, with a third of their employees able to return to work. Mines also reopened at reduced capacity. Alcohol sales remain banned, but a ban on cigarette sales was lifted. Some schools will reopen, but with limited class sizes. Public transport will increase but it is recommended that passengers wear facemasks. Ramaphosa has warned that most people should remain at home, public gatherings remain banned, travel between provinces is still prohibited, and the country's borders will stay closed.

In addition to stringent lockdown measures, South Africa is the only African country to test extensively for COVID-19 infection. A total of 268064 tests were conducted as of 6 May 2020, with about a third taking place in the public sector (African Arguments, 2020; as, 2020). Additional public health measures include the redeployment of 28000 HIV and TB contact tracers to identify and contain potential outbreak clusters within low-income communities (Nordling, 2020; Peralta, 2020). The country’s public and private healthcare sectors have largely been able to cope with the number of infections to date. However, Alex van den Heever, health economist at the University of the Witwatersrand, indicates that there are just over 1000 intensive care unit beds in state hospitals and double that in private hospitals equipped with ventilators (Bauer, 2020). On April 27, more than 200 Cuban doctors arrived in South Africa (BBC News, 2020b), despite criticism from the United States government (Africanews, 2020). As of 19 May 2020, there were 16483 confirmed cases of COVID-19 and 286 related deaths, still the highest on the continent (African Arguments, 2020; as, 2020).

The enduring burdens of HIV and TB

Restrictions on movement have been central to South Africa’s way of dealing with nearly eight million people living with HIV, with TB rampant, and with countless other immune-system threats. South Africa has the highest number of people living with HIV in the world. With 20.4% of adults (15–49 years) living with HIV, an estimated 320000 ill with TB annually, and almost 80000 TB-related deaths each year (Kanabus, 2020; WHO, 2018), disease poses a significant burden on the health sector and economy. South Africa spends more than 13% of its public resources on national and provincial health programmes and its combined spending is 4% of the Gross Domestic Product, USD 180 per capita (UNICEF, 2020). A quarter of the national health budget is dedicated to HIV, maternal health, and TB. In order to sustain progress in HIV treatments, what is currently the world’s largest HIV programme, the government with international funding partners PEPFAR and the Global Fund, spend more than USD 1.5 billion annually on prevention, care, and treatment initiatives (Guthrie et al., 2018).

Despite these significant current investments, South Africa’s original slow state response to the HIV epidemic is blamed for current high rates of HIV and TB. Treatments, now known to prevent HIV transmission by reducing viral load, were not available in South Africa’s public healthcare sector until 2004 given former President Thabo Mbeki’s denialist perspective. A comprehensive prevention-of-mother-to-child-transmission programme distributing Nevirapine to pregnant mothers and their children, only began in 2002 following a Constitutional Court ruling (Burton et al., 2015). Such delays allowed the virus to spread largely unabated for 25 years.

High rates of disease are also attributed to South Africa’s enduring inequality (Gini coefficient remaining around 0.60 since 1992), poverty (unemployment stood at 28.7% in the December 2019), migratory labour practices, and gender power imbalance. According to the report, ‘Men, Women and Children: Findings of the Living Conditions Survey 2014/15’ (2018), approximately half of the adult population in South Africa live below the upper-bound poverty line (1227 ZAR per person per month, or USD 2.15 per person per day). The consumer debt load has continued to rise, with 41% of the country’s 22 million borrowers from the formal credit system (and millions more who borrow informally) over three months behind in payments, according to the National Credit Regulator (Bond, 2020). National statistics indicate that 44.3% of households receive social grants (News24, 2019), this includes 18 million single mothers and the elderly. Mothers receive a mere USD 24 a month (down USD 14 since 1994) (Bond, 2020). No government issued unemployment insurance is available for the informal sector that comprises 18% of all employed (Nackerdien & Yu, 2019), of which women comprise 57% (Valodia, 2001). Models have shown that high levels of internal labour migration significantly contributed to the spread of HIV and TB between urban and rural areas, with poor working conditions further increasing disease transmission and morbidity (Lurie & Williams, 2014).

Adult females experience higher levels of poverty than males and consequently are disproportionally affected by HIV. Of the adults living with HIV, 62.7% are women (UNAIDS, 2018). New HIV infections among young women aged 15–24 years are more than double those among young men (UNAIDS, 2018). Adolescent girls and young women in South Africa are further burdened by high rates of gender-based violence. Studies indicate that in South Africa women with violent or controlling male partners are 1.5 times more likely to acquire HIV compared to women who had not experienced partner violence (Dunkle et al., 2004; Jewkes et al., 2010). Gender-based violence in South Africa is exacerbated by unemployment and poverty, as women are dependent on male partners (Karim & Baxter, 2016).

Poor housing further contributes to disease transmission, particularly airborne diseases such as TB. Estimates in 2007 indicated that a quarter of South Africa’s population live in the 76 largest townships in the country (Pernegger & Godehart, 2007). While within townships there is significant socioeconomic diversity, they remain densely populated, underserviced, and crime ridden. Official South African government statistics released in 2017, indicate that 14% of South Africans live in informal dwellings (Stats SA, 2018), defined as a ‘makeshift structure that is not erected in terms of approved architectural plans such as corrugated iron shacks or shanties’ (SERI, 2018, p. 6). Despite significant efforts made by the national government to address housing needs, housing remains a contentious political issue resulting in violent protests. There is a significant backlog in housing projects, with many people waiting decades before receiving housing. Furthermore, residents of government houses express concerns regarding the safety of the structures (Stats SA, 2018), the houses are generally very small (30–45 m²) (Moolla et al., 2011), accommodate large families, and have renters living in informal structures erected on vacant spaces at the back of houses (Osman, 2017). Cold South African winters further contribute to disease spread as people crowd into poorly ventilated spaces.

These social conditions create an ideal environment for the rapid transmission of a respiratory infection like COVID-19 and consequently require a response that accommodates to the unique arrangement of conditions. Ramaphosa indicated that he followed China’s lead in electing for a strict lockdown recognising the positive effect it had to contain the virus in the city of Wuhan (Yamei, 2020). But, Wuhan city is not comparable to the entire nation of South Africa where crowded, densely populated urban townships and informal settlements, are breading grounds for the virus. Maintaining social distancing or quarantining the infected is nearly impossible, hygiene practices through routine handwashing with soap and water becomes a challenge if water (and soap) is inaccessible, needing to be routinely collected from communal standpipes or taps outside the home, and unaffordable, particularly given lack of employment and additional use to address virus transmission concerns. Poverty conditions are exacerbated given loss of jobs in the largely informal economic sector, contributing to malnutrition because of food shortages. Poverty also contributes to higher rates of interpersonal violence (Makanga et al., 2017), increasing risk of HIV, and exacerbating stress-related non-communicable health conditions including diabetes and heart disease. As Mayosi et al. (2009) report, in South Africa non-communicable diseases like diabetes are increasing ‘in both rural and urban areas, most prominently in poor people living in urban settings, and are resulting in increasing pressure on acute and chronic health-care services’. Finally, limited or interrupted access to social services such as schools, which provide meals and health services to children, and health centres, which are already overburdened and now shifting efforts to address COVID-19, worsen existing health problems including malnutrition, HIV, and TB, thereby increasing COVID-19 infectivity and potentially worsening disease outcomes. Locking down the country because it worked in China does not seem like an informed approach, and arguably does not responsibly address the current social, economic, and epidemiologic conditions in South Africa.

A syndemic of concern

Of further concern for South Africa’s healthcare system and society is the interactive nature of HIV and TB, as well as HIV and TB with other diseases including known interactions with diabetes and possible unknown interactions with novel diseases such as COVID-19. During the global peak of the HIV pandemic, a group of medical anthropologists and colleagues involved in community research with high-risk groups in the United States recognised the importance of examining disease clustering in a population (Singer, 1996). They came to realise that the adverse interaction of co-present diseases combined with harmful social conditions promote both disease clustering and interaction, as well as population vulnerability to disease. They labelled the biosocial complex of interacting diseases and social conditions syndemics. Medical anthropologists, epidemiologists, medical researchers and researchers from a number of other health professions found the syndemics concept both useful in understanding and responding to the HIV pandemic and also to a growing range of other diseases (Singer et al., 2017; Singer et al., 2020).

A syndemic of ongoing concern involves HIV and TB. A large body of research indicates that HIV and TB can cluster in a population and magnify the adverse outcomes of these two widespread diseases. TB and HIV interact biologically in two primary ways. HIV kills immune system cells allowing the TB bacteria (primarily Mycobacterium tuberculosis) to move from latent to active infection and to destroy lung cells or other tissues. HIV disease progression and HIV transmission at the population level, in turn, accelerates in the presence of TB (Day et al., 2004). As the degree of immunosuppression increases in people living with HIV, the risks of developing active TB disease upon exposure also increase (McShane, 2005). These diseases interact on a social level as well, through structural vulnerabilities such as malnutrition, living in close and crowded quarters, exposure to violence, having poor healthcare access, and other stressful life conditions. These kinds of conditions are known to promote poor health (Wilkinson & Marmor, 2003).

COVID has already proven to be a highly syndemic disease known to interact adversely with diabetes, cardiopulmonary conditions, and kidney diseases. There is growing concern about interaction with HIV and TB. People with COVID-19 and TB show similar symptoms, including cough, fever, and difficulty breathing. Both diseases primarily attack the lungs and although both are usually transmitted through close interpersonal contacts, the incubation period from the point of exposure to until the development of symptoms in TB is longer. As the Pan American Health Organization (PAHO, 2020) notes, ‘While experience on COVID-19 infection in TB patients remains limited, it is anticipated that people ill with both TB and COVID-19 may have poorer treatment outcomes, especially if TB treatment is interrupted’. Notably, research by Workneh and co-workers (2016) has shown that diabetes is associated with increased mortality among people being treated for TB. Moreover, by the second month of treatment for TB patients with diabetes were more symptomatic compared to those without diabetes. These findings are supported by other research indicating significant adverse effects of diabetes on TB treatment outcomes, including treatment failure, increased risk of death, and relapse (Baker et al., 2011; Dooley et al., 2009). COVID-19 interaction with HIV also is still unclear but people living with HIV and not on treatment or whose HIV infection has not been fully suppressed may be at a greater risk. Existing preliminary research in Spain suggest people with HIV who are on treatment did not fare worse than other COVID-19 patients, but the sample size was small, most were virologically supressed, and most did not have other pre-existing conditions (Blanco et al., 2020). Unlike Spain, however, HIV is hyper-endemic in parts of South Africa with prevalence rates exceeding 20% among adults (UNAIDS, 2018). Moreover, 16% of people with HIV in South Africa who are not in treatment have been found to already have drug-resistant HIV and more than 50% of those in treatment have resistance to at least one HIV drug (Moyo et al., 2019).

In early May, Health Minister Zweli Mkhize announced that hypertension, diabetes, and cardiac disease are the most common co-morbidities associated with serious COVID-19 cases in South Africa (Singh, 2020). Other comorbidities present in admitted COVID-19 patients, Mkhize reported were chronic pulmonary disease, asthma, chronic renal disease, malignancy, HIV, and active and past TB cases. The comorbidities are exacerbated by social conditions. Despite various policy interventions targeted at reducing disparities in socio-economic inequalities in health and healthcare in post-Apartheid South Africa, significant disparities remain. As Benatar (2013) stresses, disparities in wealth and health in South Africa ‘are among the widest in the world’. Key health disparities include maternal, infant and child mortality, non-communicable/chronic disease rates, violent injury, and access to and quality of health care (Mayosi et al., 2009; Omotoso & Koch, 2018). The social drivers of these health disparities that also are part of the predominant syndemics of South Africa include a high level of unemployment, ethnic and gender disparities in employment and income that reflect the enduring legacy of apartheid, and an unequal educational system (World Bank, 2018).

Ramifications of the lockdown response

It is evident that COVID-19 poses a grave threat to South Africa. However, the strict COVID-19 lockdown implemented in response could have long-lasting public health ramifications that transcend the immediate health risks posed by the virus. Although now relatively successful at providing HIV treatments, with the support of international partners, South Africa’s health sector continues to struggle. Finance Minister Tito Mboweni cut the health budget by USD 250 million in February 2020 (Bond, 2020), further limiting abilities to respond not only to COVID-19, but to existing health challenges. South African Communist Party members confessed that,

We have been far too timid in driving forward a comprehensive National Health Insurance. We have allowed our public health system to be hugely overstretched long before the arrival of the coronavirus, allowing the bulk of health resources to be enjoyed by the 16 percent of South Africans with access to private health care. (Bond, 2020)

Of concern is that treatment for both TB and HIV might be deterred or delayed because of the COVID-19 crisis, hospital overload, and fear of COVID-19 exposure (Jiang et al., 2020). There is evidence that the gains made over recent years in reducing the rates of, and deaths from TB, in South Africa and other countries in the global South (including India) are being reversed (Pai, 2020). Given the severity of the lockdown, there are likely to be significant interruptions to other healthcare services. Patients may be nervous to seek care for emergency conditions such as heart attacks or strokes, or limit routine check-ups for chronic conditions such as diabetes or renal failure.

Globally, the drastic reduction in commercial and charter flights is impacting vaccine campaigns and immunisation schedules. According to UNICEF spokesperson Marixie Mercado, a massive backlog of vaccine shipments is mounting ‘due to unprecedented logistical constraints related to COVID-19 mitigation measures including lockdowns in some countries’ (BBC World News, 2020). Furthermore, individuals are unable to maintain childhood immunisation schedules given lockdown measures, the closing of non-emergency healthcare services, and schools – a site for childhood immunisations including the Human Papilloma Virus (HPV) vaccine. UNICEF warns that measles outbreaks might occur as a result of vaccine programmes being delayed by the COVID-19 outbreak (BBC World News, 2020).

Financially, South Africa’s weakening economy was given a ‘junk’ investment-grade credit rating by Moody’s Investment Services on March 27 due to ‘unreliable electricity supply, persistent weak business confidence and investment as well as long-standing structural labour market rigidities [that] continue to constrain South Africa’s economic growth’ (Naidoo, 2020). Economically, South Africa’s GDP growth is expected to drop by 5–10% during 2020. The collapse could cause the loss of 3–4 million jobs in both the formal and informal sectors (Bauer, 2020; Bond, 2020). Ramaphosa announced an economic relief package worth USD 26 billion, 10% of South Africa’s entire GDP, intended to protect companies and three million workers (BBC News, 2020d). The measures include tax relief, wage support through an unemployment insurance fund (only for those employed in the formal economy), and funding to small businesses (owned by South African nationals). Conversely, finance Minister Mboweni has suggested the need for significant economic reforms, including budget austerity, civil service cuts, higher levels of cost recovery, and the privatisation or closure of money-losing parastatal agencies (Bond, 2020). He has also threatened to turn to the International Monetary Fund for loans.

At the individual level, a global recession will result in limited employment options. Minimal or no income is known to increase disease risk through malnutrition, high stress levels, the compensatory consumption of alcohol, engagement in risk behaviours, dependence on abusive partners, and living conditions that contribute to disease spread (including the sharing of poorly ventilated living spaces with many people and reliance on poorly maintained public sanitation facilities). Exemplary, residents of Nelson Mandela Bay’s Westville township reported to a journalist that only half of the 40 communal water taps were working and there remained no formal electricity connections; conditions that had existed since 2000 and were unlikely to be fixed now (Bond, 2020). Electricity prices have roughly tripled in real terms over the past decade, with tariffs approved in 2019 to increase prices an additional 25% in the next three years. Consequently, poorer households continue to use fuels like gas and paraffin, a leading cause of poisoning among South African children, and a severe fire hazard in densely populated townships and informal settlements (de Greef, 2019). Finally, it is anticipated that individual-level economic hardship will result in a rise in already high domestic violence and petty crime (Bond, 2020).

Conclusion

Despite the global nature of the COVID-19 pandemic, local historic, health, and socio-environmental factors shape the epidemiological contours, response, and social challenges present within each affected nation. South Africa’s stringent lockdown measures developed in the context of the country’s burdensome history with infectious diseases. High rates of diseases that weaken the immune system and interact biologically and socially with one another already exist, potentially increasing infectivity and heightening COVID-19 mortality. Recent budget cuts to the already struggling public health sector raised internal doubts as to whether it could successfully manage yet another disease epidemic.

Yet, the lockdown itself poses significant economic risks particularly to an economy entering a recession. The country has high rates of unemployment, increasing consumer debt, a large informal employment sector with no social safety nets, mismanaged state-provided services, and overstretched social services. Offering a collective, multidisciplinary perspective on the effects of South Africa’s lockdown, Imran Valodia et al. (2020) argue that the lockdown poses a greater threat than COVID-19 syndemics. In their view, ‘It is not possible to contain the spread through lockdowns’, and furthermore, that the virus will continue to spread even after easing lockdown measures (Valodia et al., 2020). Instead, they (2020) suggest that citizens engage in ‘collective cooperation’, complying with evidence-based behaviour (e.g. handwashing, wearing a facemask) and societal change (e.g. increasing store and public transport hours to reduce density). However, these suggestions fail to account for the challenges inherent in what some may view as simple acts of behaviour change. Routine, consistent, and effective handwashing is not always possible in townships or rural areas where water is in limited supply, expensive, inaccessible, or contaminated. Wealthier South African’s may be able to limit their use of public transportation and avoid busy store hours given flexible work hours or working from home. This is a luxury most South Africans do not share, as the majority of the working population live in densely populated townships on the outskirts of major economic hubs or migrate to urban areas from homes in rural towns.

South Africa’s lockdown resulted in immediate job loss for millions of formal and informal workers and created numerous hardships such as securing water, electricity, food, safety, and shelter to a significant portion of the population. Another country with significant social and health in equalities has adopted a starkly contrastive response to the one seen in South Africa, there is the case of Brazil. Similar to South Africa, 13 million Brazilians live in densely packed favelas where they have little opportunity to implement social distancing and preventive hygiene measures. The large informal employment sector is no longer an option as a source of income. The Indigenous population in rural areas, under threat even before COVID-19 due to illegal mining and logging that has been ongoing in the Amazon rainforest, are exposed to infectious disease from loggers and miners coming from urban areas. Amazonas state had almost 21,000 confirmed cases as of mid-May (BBC News, 2020a). According to the advocacy group, Articulation of Indigenous Peoples of Brazil, the mortality rate among indigenous people is 12.6%, double the national rate of 6.4% (Darlington et al., 2020). A primary contributing factor is the lack of access to necessary healthcare. Estimates from a study by the non-profit InfoAmazonia indicate that the average distance to an intensive care unit from indigenous villages is 315 km, with 10% of villages being more than 700 km from a hospital that could provide intensive care (Darlington et al., 2020).

Yet Brazil has imposed no national policies to reduce social contact or require social distancing. President Jair Bolsonaro, who has dismissed the risks and compared Covid-19 to ‘a little flu’, strongly opposes lockdown measures, and has called on mayors and governors to roll back any restrictions they may have imposed arguing that such measures will wreck the economy (BBC News, 2020a). The result is a country in turmoil. Two health ministers have left Bolsonaro’s administration in the span of a month, after clashing with the president over his response to the COVID-19 pandemic (Phillips & Agren, 2020). In addition to defending quarantine measures imposed by mayors and governors, health ministers Teich and Mandetta refused to endorse Bolsonaro’s calls for the widespread use of the anti-malaria drug hydroxychloroquine (Londoño, 2020). Bolsonaro ordered the armed forces pharmaceuticals laboratory to mass-produce the drug, despite the lack of evidence of efficacy and known serious side effects.

Brazil has the second-highest number of confirmed COVID-19 infections in the world and the most COVID-19 cases and deaths in Latin America. Experts suggest that the real figure could be 15 times higher, given insufficient testing (BBC News, 2020a). The mayor of Brazil’s largest city, Sao Paulo, warned that the city’s health system could collapse within two weeks (BBC News, 2020a). Similarly, hospitals in other major cities like Belem, Manaus, and Fortaleza report they lack the number of beds needed to treat coronavirus patients. The rapid spread of coronavirus since the first case was diagnosed on 25 February 2020, in combination with the ‘political vacuum’ at the national level (The Lancet, 2020), an unprepared healthcare system, and significant health disparities and pre-existing health conditions among the poor portend a severe COVID-19 syndemic in Brazil.

The COVID-19 epidemic in South Africa, Brazil, and worldwide, has reminded us that disease threats and burdens, although global, are not universally shared. COVID-19 syndemics in South Africa’s are likely to cluster among the economically, politically, and socially marginalised living in densely populated urban areas, where physical distancing and hygiene recommendations are nearly impossible to follow. Individuals are unable to engage in ‘collective cooperation’ to reduce their own risk while the weak and overburdened public health sector and social safety nets are unable to assist in establishing less risky environments or responding to high disease rates. The lockdown has temporarily spared South Africans from the worst that COVID-19 can inflict, but it has highlighted and exacerbated severe shortcomings and inequities in the national public health sector and social welfare programmes that no lockdown can adequately address.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Correction Statement

This article has been republished with minor changes. These changes do not impact the academic content of the article.